Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 58
Assessment and Management
of Patients With Eye and
Vision Disorders

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
Strabismus is involuntary oscillation of the eyeball.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
False
Nystagmus is involuntary oscillation of the eyeball.
Strabismus is a condition in which there is deviation from
perfect ocular alignment.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
External Structures of the Eye

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Extraocular Muscles

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Visual Pathways

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cross-Section of the Eye

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Internal Structures of the Eye
• Refer to fig. 58-4

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment and Evaluation of Vision
• Ocular history
• Visual acuity
– Snellen chart
• Record each eye
• 20/20 means the patient can read the “20” line at
a distance of 20 feet
• Finger count or hand motion

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Examination of the External Structures
• Note any evidence of irritation, inflammatory process,
discharge, etc.
• Assess eyelids and sclera
• Assess pupils and pupillary response; use darkened room
• Note gaze and position of eyes
• Assess extraocular movements
• Ptosis: drooping eyelid
• Nystagmus: oscillating movement of eyeball

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic Evaluation
• Ophthalmoscopy
– Direct and indirect
– Examines the cornea, lens and retina
• Slit-lamp examination
• Color vision testing
• Amsler grid
• Ultrasonography
• Fluorescein and indocyanine green angiography

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic Evaluation
• Tonometry
– Measures intraocular pressure
• Gonioscopy
– Visualizes the angle of the anterior chamber
• Perimetry testing
– Evaluates field of vision
– Scotomas: blind areas in the visual field

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Impaired Vision
• Refractive errors
– Can be corrected by lenses which focus light rays on
the retina
• Emmetropia: normal vision
• Myopia: nearsighted
• Hyperopia: farsighted
• Astigmatism: distortion due to irregularity of the cornea

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Eyeball shape determines visual acuity in
refractive errors

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Glaucoma
• A group of ocular conditions in which damage to the optic
nerve is related to increased intraocular pressure (IOP)
caused by congestion of the aqueous humor
• The leading cause of blindness in adults in the U.S.
• Incidence increases with age
• Risk factors

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pathophysiology of Glaucoma
• Normal Outflow of Aqueous
Humor
• Refer to fig. 58-7
• In glaucoma, aqueous
production and drainage are
not in balance.
• When aqueous outflow is
blocked, pressure builds up
in the eye.
• Increased IOP causes
irreversible mechanical
and/or ischemic damage.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Types of Glaucoma
• Open-angle
– Chronic open angle glaucoma
– Normal tension glaucoma
– Ocular hypertension
• Angle-closure (pupillary block) glaucoma
– Acute angle-closure
– Subacute angle-closure
– Chronic angle-closure
• Congenital glaucomas and glaucoma secondary to other
conditions

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Manifestations
• “Silent thief”; unaware of the condition until there is
significant vision loss; peripheral vision loss, blurring,
halos, difficulty focusing, difficulty adjusting eyes to low
lighting
• May also have aching or discomfort around eyes or
headache

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic Findings
• Tonometry to assess IOP
• Gonioscopy to assess the
angle of the anterior
chamber
• Perimetry to assess vision
loss
• Progression of visual field
defects
• Refer to fig. 58.8

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Treatment
• Goal is to prevent further optic nerve damage
• Maintain IOP within a range unlikely to cause damage
• Pharmacologic therapy
• Surgery
– Laser tribeculoplasty
– Laser iridotomy
– Filtering procedures
– Tribeculectomy
– Drainage implants or shunts

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Management
• Patient education.
• Focus on maintaining the therapeutic regimen for lifelong
control of a chronic condition.
• Emphasize the need for adherence to therapy and
continued care to prevent further vision loss.
• Provide education regarding use and effects of
medications.
• Medications used for glaucoma may cause vision
alterations and other side effects. The action and effects
of medications need to be explained to promote
compliance.
• Provide support and interventions to aid the patient in
adjusting to vision loss/potential vision loss.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cataracts
• An opacity or cloudiness of the lens
• Increased incidence with aging; by age 80 more than half
of all Americans have cataracts
• A leading cause of disability in the U.S.
• Risk factors

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cataract

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical Manifestations
• Painless, blurry vision
• Sensitivity to glare
• Reduced visual acuity
• Other effects include myopic shift, astigmatism, diplopia
(double vision), and color shifts including brunescens
(color value shift to yellow-brown)
• Diagnostic findings include decreased visual acuity and
opacity of the lens by ophthalmoscope, slit-lamp, or
inspection

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Surgical Management
• If reduced vision does not interfere with normal
activities, surgery is not needed.
• Surgery is preformed on an outpatient basis with local
anesthesia.
• Surgery usually takes less than 1 hour and patients are
discharged soon afterward.
• Complications are rare but may be significant.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Types of Cataract Surgery
• Intracapsular cataract extraction (ICCE): removes
entire lens, rarely done today
• Extracapsular cataract extraction (ECCE): maintains
the posterior capsule of the lens, reducing potential
postoperative complications
• Phacoemuslification: an ECCE which uses an ultrasonic
device to suction the lens out through a tube; incision is
smaller than with standard ECCE
• Lens replacement: after removal of the lens by ICCE or
ECCE, the surgeon inserts an intraocular lens implant
(IOL). This eliminates the need for aphakic lenses,
however, the patient may still require glasses.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Management
• Preoperative care
• Usual preoperative care for ambulatory surgery
• Dilating eye drops or other medications as ordered
• Postoperative care
• Patient teaching
• Provide written and verbal instructions
• Instruct patient to call physician immediately if vision
changes; continuous flashing lights appear; redness,
swelling, or pain increase; type and amount of drainage
increases; or significant pain is not relieved by
acetaminophen

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Corneal Disorders
• Treatment of diseased corneal tissue
– Phototherapeutic keratectomy
– Keratoplasty
– Use of donor tissue for transplant
– Need for follow-up and support
– Potential graft failure; teach signs and symptoms
• Refractive surgery
– Elective procedures to recontour corneal tissue and correct
refractive errors
– Patient need counseling regarding potential benefits, risks,
and complications.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
LASIK
• Refer to fig. 58-10

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Retinal Disorders
• Retinal detachment
• Retinal vascular disorders
– Central retina vein occlusion
– Branch retinal vein collusion
– Central retinal vein occlusion
– Macular degeneration

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Retinal Detachment
• Separation of the sensory retina and the RPE (retinal
pigment epithelium)
• Manifestations: sensation of a shade or curtain coming
across the vision of one eye, bright flashing lights,
sudden onset of floaters
• Diagnostic findings: assess visual acuity, assessment of
retina by indirect ophthalmoscope, slit-lamp, stereo
fundus photography, and fluorescein angiography.
Tomography and ultrasound may also be used

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Retinal Detachment

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Surgical Treatment
• Scleral buckle
• Pars plana vitrectomy
– Removal of vitreous locating the incisions at the pars
plana
– Frequently used in combination with other
procedures
• Pneumatic retinoplexy
– Injected gas bubble, liquid, or oil is used is used to
flatten the sensory retina against the RPE
– Postoperative positioning is critical

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Scleral Buckle

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Management
• Patient teaching
– Eye surgery is most often done as an outpatient
procedure so patient education is vital
– Signs and symptoms of complications, especially
increased IOP and infection
• Promote comfort
• Patient may need to lie in a special position with
pneumatic retinoplexy

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Retinal Vein or Artery Occlusion
• Loss of vision can occur from retinal vein or artery
occlusion
• Occlusions may result from atherosclerosis, cardiac
valvular disease, venous stasis, hypertension, or
increased blood viscosity; and associated risk factors are
diabetes mellitus, glaucoma, and aging.
• Patient may report decreased visual acuity or sudden loss
of vision

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Macular Degeneration
• Age-related macular degeneration (AMD)
• The most common cause of vision loss in persons older
than age 60
• Types
– Dry or nonexudative type; most common, 85–90%
• Slow breakdown of the layers of the retinal with
the appearance of drusen
– Wet type
• May have abrupt onset
• Proliferation of abnormal blood vessels growing
under the retina—choroidal revascularization
(CNV)

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Vision Loss Associated with Macular
Degeneration
• Refer to fig. 58-15

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Retina Showing Drusen and AMD

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Progression of AMD: Pathways to Vision
Loss

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Photodynamic Therapy for Slowing
Progression of AMD
• Light-sensitive verteporfin dye is injected into vessels. A
laser then activates the dye, shutting down the vessels
without damaging the retina.
• The result is to slow or stabilize vision loss.
• Patient must avoid exposure to sunlight or bright light for 5
days after treatment to avoid activation of dye in vessels
near the surface of the skin.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Management
• Patient teaching
• Supportive care
• Promote safety
• Recommendations to improve lighting, magnification
devices, and referral to vision center to
improve/promote function

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Trauma
• Prevention of injury
• Patient and public education
• Emergency treatment
– Flush chemical injuries
– Do not remove foreign objects
– Protect using metal shield or paper cup
• Potential for sympathetic ophthalmia causing blindness in
the uninjured eye with some injuries

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Protective Eye Patches

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Infectious and Inflammatory disorders
• Dry eye syndrome
• Conjunctivitis (“pink eye”)
– Classified by cause—bacterial, viral, fungal, parasitic,
allergic, toxic
– Viral conjunctivitis is contagious
• Uveitis
• Orbital cellulitis

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hyperemia in Viral Conjunctivitis

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Ocular Consequences of Systemic Disease
• Diabetic retinopathy
– Diabetes is a leading cause of blindness in people
age 20–74
• Ophthalmic complications associated with AIDS
• Eye changes associated with hypertension

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Ophthalmic Medications
• Ability of the eye to absorb medication is limited.
• Barriers to absorption include the size of the conjunctival
sac, corneal membrane barriers, blood-ocular barriers,
and tearing, blinking, and drainage
• Intraocular injection or systemic medication may be
needed to treat some eye structures or to provide high
concentrations of medication.
• Topical medications (drops and ointments) are most
frequently used because they are least invasive, have
fewest side effects, and permit self administration.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Ophthalmic Medications
• Topical anesthetics
• Mydriatics (dilate) and cycloplegics (paralyze)
– Contraindicated with narrow angles or shallow
anterior chambers and inpatients on monoamine
oxidase inhibitors or tricyclic antidepressant
– May cause CNS symptoms and increased BP
especially in children or the elderly
• Anti-infective medications
– Antibiotic, antifungal, or antiviral products

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Ophthalmic Medications
• Medications used for glaucoma
– Increase aqueous outflow or decrease aqueous
production
– May constrict the pupil and may affect ability to focus
the lens of the eye; affects vision
– May also may produce systemic effects
• Anti-inflammatory drugs; corticosteroid suspensions
– Side effects of long-term topical steroids include
glaucoma, cataracts, and increased risk of infection.
To avoid these effects, oral NSAID therapy may be
used as an alternate to steroid use

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Low Vision and Blindness
• Low vision
– Visional impairment that requires devices and
strategies in addition to corrective lenses
– Best corrected visual acuity (BCVA) of 20/70 to
20/200
• Blindness
– BCVA 20/400 to no light perception
– Legal blindness is BCVA that does not exceed 20/200
in better eye or widest filed of vision is 20 degrees or
less
• Impaired vision often is accompanied by functional
impairment

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment of Low Vision
• History
• Examination of distance and near visual acuity, visual
field, contrast sensitivity, glare, color perception, and
refraction
• Special charts may be used for low vision
• Nursing assessment must include assessment of
functional ability, and coping and adaptation in
emotional, physical, and social areas

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Management
• Support coping strategies, grief processes and acceptance of
visual loss
• Strategies for adaptation to the environment
– Placement of items in room
– “Clock method” for trays
• Communication strategies
• Collaboration with low-vision specialist, occupational therapy or
other resources
• Braille or other methods for reading/communication
• Service animals

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Safety Measures and Teaching
• Patient teaching is a vital nursing intervention for patient
with eye and vision disorders
• Prevention of eye injuries; education
• Safety strategies for patients with low vision in the
hospital and home setting
• Patient teaching after eye surgery or trauma
– Potential complications
– Loss of binocular vision with patch or vision
impairment of one eye; safety
– Use of eye patch and shield

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Which medication is administered for glaucoma, uveitis, or
after surgery?
A.Atropine
B.Cyclopentolate
C.Phenylephrine
D.Tropicamide

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A
A.The medication that is administered for glaucoma,
uveitis, or after surgery is atropine. Cyclopentolate,
phenylephrine, and tropicamide are administered for
pupillary dilation for opthalmoscopy and surgical
procedures.